Faculty/Staff PWU New Client Form


Today’s Date: ____________________
PERSONAL INFORMATION
Please Check One:  ____Student ____Faculty/Staff   ____ Affiliate ____Spouse-Student ____Spouse-Faculty/Staff
Please Check One:  ____Dr.   ____Rev  ____Mr.  ____Mrs.  ____Ms.
Name:_____________________________________________   _____Male   _____Female
Date of Birth:______________________________    Datatel #:___________________________
Address:________________________________  City:_______________  State:_______  Zip:____________
Day Phone: (_____)____________  Evening Phone: (_____)_________           Cell Phone: (_____)___________
Email address:______________________________      How frequently do you check email?________________
Emergency Contact:________________________________            Relationship:__________________________
Emergency Contact Phone: (______)__________¬¬¬_________


TRAINING INFORMATION
What personal training service are you purchasing?
_____Single Session A  _____Single Session B  _____Faculty/Staff PWU Session
_____3  _____6   _____13  _____21 _____29 
_____Tag Team 6  _____Tag Team 10  _____Tag Team 12
When is the best time to contact you by phone?_________________________________________________
When would you like to begin your personal training program?____________________________________
What day(s) and time(s) are you looking to schedule your personal training sessions?____________________
________________________________________________________________________________________
Trainer Preference: _____Male Trainer  _____Female Trainer   _____No Preference
Is there a particular trainer with whom you would like to work with?__________________________________
Additional Comments:______________________________________________________________________
How did you hear about the Personal Training Program:  ___Website  ___Pendulum  ___Friend
___ Fitness Center ___Other:______________________

PHYSICAL ACTIVITY
1. Height:__________ Weight:__________
2. In the past year, how often have you engaged in physical activity?
_____Regularly (3-4 times/week)    _____Semi regularly (1-2 times/week)
_____Sporadic (1 to 2 times/month)    _____None
3. What are your personal barriers for not exercising or sticking to a program?_________________________
___________________________________________________________________________________
4. How much time do you plan on spending on your workout program?
_____Minutes/Day  _____Day/Week

EXPECTATIONS
1. Why have you decided to begin or improve your exercise program?_______________________________  ________________________________________________________________________________________  ________________________________________________________________________________________
2. Why have you decided to hire a personal trainer?
• Need motivation and accountability
• Improve physical fitness
• Weight loss
• Improve strength
• Boredom with current workout
• Want to learn more about fitness
• Other?____________________________
3. Specifically describe what you would like to accomplish in your personal training sessions? ___________________________________________________________________________________ ___________________________________________________________________________________
4. Specifically describe what you would like to accomplish through your fitness program during the next:
• 1 month:______________________________________________________________________
• 4 months:______________________________________________________________________
• 1 year:________________________________________________________________________

 


MEDICAL INFORMATION
Please indicate whether you CURRENTLY HAVE or PREVIOULSY HAVE HAD a significant problem with any of the symptoms or conditions listed below:
Condition Yes No Don’t Know Comments
Unexplained weight loss or gain   
Chronic fatigue   
Change in appetite   
Cancer   
Chest pain or pressure   
Chest pain with exertion   
Heart attack   
Rapid or irregular heart beats   
Fainting, dizziness, or lightheadedness   
High blood pressure   
Stroke   
High blood cholesterol   
High blood triglycerides   
Diabetes   
Hypoglycemia/Low blood sugar   
Asthma   
Unexplained shortness of breath during physical activity   
Chronic joint or muscle pain   
Back pain   
Arthritis or Rheumatic condition   
Bone, joint, or muscular injury   
Surgical procedures   
Thyroid disease   
Epilepsy   
Eating disorder   
Persistent Headache   
Bursitis   


Please list any additional medical concerns/conditions that might limit your ability to participate in this program (pregnancy, disability, recent surgery, etc): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list current medications including overt-the counter medications, prescriptions, etc.
Medication Dosage Reason for Taking
 
 
 
 
 

Known Allergies (Environmental, Medications, Food, etc.): _________________________________________________________________________________________________

FAMILY MEDICAL HISTORY
Please indicate if any family member has had any of the following:
Medical Condition Relationship Comments
Heart attack 
Stroke 
Cardiovascular disease 
High blood pressure 
High cholesterol 
Diabetes 
Obesity 
Cancer 
Osteoporosis 
Other